Comorbidity of alcoholism and psychiatric disorders: an overview

Alcohol Research & Health, Spring, 2002 by Ismene L. Petrakis, Gerardo Gonzalez, Robert Rosenheck, John H. Krystal

In a series of papers produced in the early 1990s, Holder and colleagues affirmed that alcoholism treatment can result in markedly reduced health care costs (Holder et al. 1991; Blose and Holder 1991). The high rates of comorbid mental disorders among people with alcohol abuse and dependence and the low rates of appropriate treatment among comorbid patients provide substantial evidence that integrated services are needed which can address both disorders. It is important for both mental health and substance abuse professionals to recognize the dual disorders and to treat them as such early in their course, because early intervention may reduce the severity of both disorders, improve the eventual outcome, and reduce health care costs.

TREATMENT

Although there has been an explosion of research on strategies for treating alcohol-related disorders, most of this research has focused on treatment for patients with a single diagnosis of alcohol abuse or dependence and not on patients with a dual diagnosis. Likewise, well-established treatments for psychiatric disorders have, for the most part, not been evaluated in patients with co-occurring alcohol-related disorders.

As a result of the recent widespread recognition of the need for more effective treatments, however, more specialized treatment for comorbid patients is becoming available. Mental health and substance abuse facilities are expanding services for patients with dual disorders, integrating psychiatric and substance abuse treatments, and seeking broader education and training for the professionals who staff these facilities. A greater understanding of the psychological and neurobiological mechanisms at work in psychiatric and substance use disorders has shaped research in this area. Although they still represent a small fraction of the research, several studies conducted during the past 5 to 10 years have investigated the use of integrated treatment for comorbid alcoholic patients. These studies have shown nor only that this research is feasible and productive but that it is useful for informing clinicians about potential effective treatments for this group of patients (e.g., Cornelius et al. 1997a,b). The followi ng sections describe the various pharmacologic and psychosocial treatments available for treating alcohol use disorders alone and with comorbid psychiatric conditions.

Pharmacologic Treatment

Several aspects of comorbidity suggest that medications may be particularly important for this group of alcoholics. First, some alcohol-dependent people with comorbid diagnoses face greater difficulties in accessing and using traditional alcoholism treatment and self-help groups in which many members do not have comorbid disorders. For example, people with pronounced paranoia or negative symptoms (e.g., social and emotional withdrawal) may be uncomfortable in a group setting or with a treatment approach that includes confrontation. Second, pharmacological treatments are generally familiar to dually diagnosed patients, because many already are used to raking medications for their psychiatric disorder, and dosage scheduling can be readily integrated into a medication schedule for the comorbid condition. Third, the cognitive symptoms common in comorbid mental disorders may undermine patients' motivation and ability to learn new material in psychosocial treatments, particularly early in recovery. For example, pat ients with thought disorders or slowed thinking secondary to depression may have difficulty concentrating and learning or completing homework assignments in treatment that is based on cognitive behavioral therapy.